Effect of Bleaching on Marginal Adaptation of

Class V Bonded Composite Restoration
Safa H A Elhakeem
a
, Hisham A Mohamed
b
, Abeer S Farag
c

a Master student in Operative Dentistry Faculty of Dentistry Minia University
b Professor of Operative Dentistry Faculty of Dentistry Ain Shams University
c Lecturer of Operative Dentistry Faculty of Dentistry Minia University
Abstract
Objectives: This investigation was carried to determine the effect of in-
office and home bleaching applied before or after restorative procedures
on the marginal adaptation of class v bonded composite restorations
utilizing different adhesive systems; self etch and total etch.
Methods: One hundred extracted sound human anterior teeth were
divided into two groups of fifty teeth each according to the type of
adhesive used; total etch ( Excite PF) or self etch (AdheSE). Each group
was further subdivided into five subgroups of 10 teeth each; B0 not
received any bleaching treatment only cavity preparation and restoration
(control), B1 received in-office bleaching ( 38% H2O2 opalescence
Boost) one week before cavity preparation and restoration, B2 received
in-office bleaching one month after cavity preparation and composite
resin restoration, B3 received home bleaching (35% carbamide peroxide,
opalescence PF) one week before cavity preparation and restoration, B4
received home bleaching one month after cavity preparation and
composite resin restoration. Class V cavity were prepared in the labial
surface of all teeth. Teeth were restored with nano hybrid composite
(Tetric Evo-Ceram) and thermocycled for 1000 cycles at 5-55◦C. Dye
penetration test were done using ammonical silver nitrate. Teeth were
sectioned and examined by scanning electron microscope. EDAX
2
microanalysis was done and the average concentrations of silver ions at
the tooth restoration interface were recorded
Results: There were statistical significant differences in silver uptake
between total etch and self etch bonded composite restorations in the
control subgroups B0 (P≤ 0.001) and in pre restorative home bleaching
B3 subgroups (P≤ 0.01). Home bleaching with total etch bonded
composite restorations B3 & B4 showed a statistically significant
(P≤0.05) lower silver uptake than other subgroups. There were statistical
significant differences (P ≤ 0.05) between pre and post-restoration home
or in-office bleaching with both adhesives except for in-office bleaching
with total etch bonded composite restorations.
Conclusion: pre and post-restoration Home bleaching doesn't adversely
affect the adaptation of nano-hybrid composite bonded with total etch or
self etch adhesive. Marginal adaptation of nano-hybrid composite to
home bleached teeth is superior to that of in-office bleaching using total
etch adhesive. Pre and Post-restoration in-office bleaching adversely
affect the adaptation of nano-hybrid composite bonded with total etch but
it didn't adverse the adaptation of composite restorations bonded with self
etch adhesive.
Introduction
Teeth-whitening or bleaching systems have caused much interest and
controversy in the area of restorative dentistry (Crim et al., in 1992).
Bleaching techniques may be classified by whether they involve vital or
non-vital teeth or by whether the procedure is performed in-office or at-
home (polydorou et al., 2007).
Nowadays tooth bleaching is based upon hydrogen peroxides as the
active agent which may be applied

directly, or produced in a chemical
reaction from sodium perborate or carbamide peroxide. Several studies
have shown changes in enamel structure, composition, and bond strength
3
when exposed to 35% hydrogen peroxide for in-office vital bleaching
(McGuckin et al., 1992; Loppes etal., 2002; Dahi and Pallesen, 2003; Lee
et al., 2006).
Bonding of resin based composite to tooth structure can be accomplished
by means of etch-and-rinse adhesive systems. The etch-and-rinse
approach has been considered technique–sensitive. In an attempt to
reduce technique-sensitivity, a second approach was developed, in which
self-etching primers were applied without further rinsing, and followed
by application of a solvent-free hydrophobic adhesive layer. Recently, a
more user–friendly one step self-etching\self-priming technique was
introduced (Reis et al., 2007). Comparison of etch-and-rinse and self-etch
systems in terms of microleakage has been well documented. However,
little information is available in the literature regarding the influence of
bleaching agents on the microleakage of these adhesive systems (Deliperi
et al., 2006; Moule et al., 2007; Yazici et al., 2010).
A scanning electron microscopic study of the adhesion of a light-
cured resin to bleached enamel has indicated that there is an alteration of
resin quality following exposure to hydrogen peroxide (Crim et al., in
1992). Some authors reported reduced bond to human dentin and
suggested a one week delay of the bonding procedure after bleaching
(Uysal et al., 2003). Other researchers suggested 3weeks gap between
bleaching and bonding procedures (Cavalli et al.,2001).
Literature showed that the bleaching agent can contain products that are
able to promote degradation of the adhesive interface, which may affect
the adaptation and reduce the longevity of the restoration (Sartori et al.,
2009). That is why practitioners suggest the use of a bleaching agent
before restorative treatment involving the use of composite resin
restorations, porcelain crowns or veneers. In cases where such
restorations are in place prior to bleaching, the restoration may need to be
4
replaced to match the shade of the whitened tooth structure. In either
situation, the restoration would be placed in tooth structure that had been
exposed to prolonged bleaching (Crim et al., in 1992) which may affect
the adaptation of restoration to cavity wall. A few studies have evaluated
the effect of bleaching on microleakage of restorations, and little is
known about the bleaching effect prior to restoration placement on
microleakage (Yazici et al., 2010)
This investigation was carried to determine the effect of in office and
home bleaching applied before or after restorative procedures on the
marginal adaptation of class v bonded composite restorations utilizing
different adhesive systems; self etch and total etch.
Methods
1- Selection of teeth:
A total of 100 extracted sound human anterior teeth were used in the
study. Teeth were cleaned, polished with NUPRO Prophylaxis Paste
(DentSply, Caulk), examined carefully using magnifying lens to exclude
any cracked tooth and stored in distilled water till use.
2-Grouping of teeth
The selected teeth were divided into two groups of fifty teeth each
according to the type of adhesive used; total etch or self etch. Each group
was further subdivided into five subgroups of 10 teeth each. The first
subgroup (B0) not received any bleaching treatment only cavity
preparation and restoration (control). The second subgroup (B1) received
in-office bleaching one week before cavity preparation and restoration.
The third subgroup (B2) received in-office bleaching one month after
cavity preparation and composite resin restoration. The fourth subgroup
(B3) received home bleaching one week before cavity preparation and
restoration. Then the fifth subgroup (B4) received home bleaching one
month after cavity preparation and composite resin restoration.
5

3-Cavity preparation and restoration:

3.1- Cavity preparation

Standardized uniform kidney shaped class V cavities were prepared in the
gingival third of the labial surface of each tooth. The cavity dimensions
were; 3.0 mm mesio-distal, 2.0 mm inciso-gingival, and 1.5 mm cavity
depth. The dimensions of the cavities were kept identical by using a
composite replica made for one cavity then the same dimensions were
duplicated in other cavities. Cavities were cut using #009 fissure diamond
burs (Komet. Germany) in a high speed air water cooled hand piece.
3.2. Restoration

Fifty cavities were restored using a total etch adhesive and nanohybrid
composite resin while the other fifty were restored using a self etch
adhesive and same composite. All restorative procedures were done
according to the manufacture instructions. In the total etch group, 37%
phosphoric acid gel (Ivoclar Vivadent, Schaan, Liechtenstein) was
applied for 30 seconds on the enamel and 15 seconds on the dentin. The
etching gel was removed with water spray for 5 seconds then excess
water was plotted with cotton pellets. The adhesive ExiTE F (Ivoclar
Vivadent, Schaan, Liechtenstein) was applied into the cavity and light
cured for 10 seconds using light emitting diode LED with spectrum
ranged from 380 to 515 nm (blue phase C8, Ivoclar Vivadent, Schaan,
Liechtenstein). In the self etch group the AdheSE primer(Ivoclar
Vivadent, Schaan, Liechtenstein) was applied and brushed into the entire
surfaces of the cavity left for 30 seconds. Then AdheSE bond was applied
to entire surfaces of the cavity and light cured for 10 seconds. Tetric
EvoCeram composite shade A3 (Ivoclar Vivadent, Schaan, Liechtenstein)
was inserted into the cavity in two increments; first increment applied to
6
the entire incisal wall down to pulpogingival line angle then cured for 40
seconds. The second increment was packed to the remainder of the cavity
then cured for 40 seconds under pressure of Myler strip. Finishing and
polishing were accomplished using sequential Soflex disc (3M ESPE,
USA) from coarse to fine.
4-Bleaching procedure:
4.1.In-office bleaching:
The teeth of subgroups B1&B2 were mounted in a cast using an
impression compound. The bleaching procedures were done according to
the manufacture instructions. The in-office bleaching agent 38%
hydrogen peroxide, Opalescence boost (Ultradent Products, South Jordan,
Utah) was applied to the labial surface of the teeth, left for 20 minutes
and agitated every 5 minutes then teeth were rinsed with water and air
dried. The bleaching process was repeated three times.
4.2. Home bleaching:
Teeth of Subgroup B3 & B4 were mounted in specially fabricated plastic
tray to facilitate stabilization of teeth during bleaching. Half of the
bleaching syringe content (35% carbamide peroxide, opalescence PF,
Ultradent Products, South Jordan, Utah) was injected in the plastic tray,
then teeth were mounted in the tray. The application period was 30
minutes per day for 14 days. After each bleaching session teeth were
rinsed and stored in distilled water.
5 –Thermocycling
All specimens were exposed to a thermocycling regimen of 1000 cycles
between 5˚ c and 55˚ c, with a 30 seconds dwell time in water bath.
(Thermocycling device, Dep of Biomaterial, Alex University).
6- Microleakage assessment and evaluation:
6.1. Dye penetration and sectioning
7
Two coats of nail varnish (Avon, USA) were applied to the entire
specimen surface except the restoration and 1mm all around the cavity
margins. Apical Foramens were sealed with sticky wax (Dentsply
DeTrey, Bois Colombes, France). A modified silver staining technique
(Tay et al., 2002) was used with basic 50wt% ammoniacal silver nitrate
(pH=9.5). The teeth were immersed into a freshly-prepared ammoniacal
silver nitrate solution and kept in black covered box for 24 hours. The
specimens were thoroughly rinsed with distilled water for 5 minutes and
placed in a photo developing solution (Kodak, Rochester, USA) for 8
hours under fluorescent light to reduce the diamine silver ions into
metallic silver grains. The teeth were then placed in distilled water for 5
minutes. The stained teeth were sectioned labio-lingual through the center
of the restoration using diamond disc in low speed hand piece with water
spray. The cut surfaces were finished, polished using sequential Soflex
disc (3M ESPE, USA) from coarse to fine and conditioned with
polyacrylic acid 10 %( 3M ESPE, USA) for 10 seconds.
6.2 Examination of marginal adaptation:
The specimens were mounted on SEM scanning electron microscope
stubs (Inspect
TM
F50, FEI Company, USA) with the cut surface exposed
for examination at working distance 10.0mm and 30kv then images were
captured.
6.3. Energy dispersive X-ray microanalysis (EDAX):
EDAX is an X-ray spectro-chemical technique which allows
determination of the local chemical composition of a solid sample by
means of an in situ, non-destructive analysis on a microscope scale. The
silver ions at the tooth restoration interface of the specimens were
identified using EDAX analysis supplied with the Scanning electron
Microscope (Genesis spectrum EDAX INC, USA). Randomly selected 3
spots at the tooth restoration interface of each specimen were analyzed at
8
magnification 1000x. The average concentrations of silver ions expressed
as weight percent were recorded and the mean was calculated for each
specimens. Then the mean concentration of silver ions was calculated for
each subgroup.
7- Statistical analysis:
Statistical analysis was carried out using SAS program (SAS, 1988). Two
way analysis of variance (Procedure GLM of SAS) was run to test the
effect of bleaching agent, adhesive system and their interaction on
marginal adaptation. One way analysis of variance (procedure ANOVA
of SAS) followed by Duncan's Multiple Range Test were used to test the
effect of bleaching agent on marginal adaptation within each adhesive
system. Student t test (Procedure Means of SAS) was used to test the
effect of adhesive systems on marginal adaptation within each bleaching
gent.
Results
Table 1 showed that in the group which restored with nano-hybrid
composite and total etch adhesive system both B1& B2 sub groups
demonstrated more significant silver uptake than control B0, B3& B4. No
statistical significant difference was observed in silver uptake with in-
office bleaching subgroups wither before B1 or after B2 cavity
preparation and restoration. Meanwhile there was a statistical significant
difference was observed between B3& B4 which treated by home
bleaching. Both B3 & B4 showed a significant lower silver penetration
than other subgroups that restored by nanohybrid composite and total etch
adhesive B0, B1&B2.
In the group that restored using nano-hybrid composite and self etch
adhesive system the highest silver ions uptake was observed in the
control B0 and B3 subgroups with no statistical significant difference
9
between both of them. While the other subgroups that bonded with self
etch adhesive system (B1, B2 & B4) showed less silver ions uptake.
Table (1): Descriptive statistics and test of significance for the effect of bleaching
agents on silver uptake within each adhesive system.

Bleaching
agent
Total etch Self etch
Mean SD dt Mean SD dt
B0
B1
B2
B3
B4
4.17 0.21 ab 5.49 0.07 a
4.42 0.44 a 4.62 0.88 ab
4.41 0.62 a 3.65 0.95 b
2.85 0.40 c 5.38 0.55 a
3.45 0.38 bc 4.27 0.54 ab
S.D.= Standard deviation.
Dt = Duncan's Multiple Range Test for the effect of bleaching agent.
Means with the same letter within each column are not
significantly different at p=0.05.
B0 = No bleaching control group
B1 = In-office bleaching before cavity preparation and restoration.
B2 = In-office bleaching after cavity preparation and restoration.
B3 = Home bleaching before cavity preparation and restoration.
B4 = Home bleaching after cavity preparation and restoration

Table (2): Descriptive statistics and test of significance for the
effect of adhesive systems on silver uptake within each bleaching agent.
Bleaching
agent
Total etch Self etch P
Mean SD Mean SD
B0
B1
B2
B3
B4
4.17 0.21 5.49 0.07 0.001***
4.42 0.44 4.62 0.88 0.75 NS
4.41 0.62 3.65 0.95 0.31 NS
2.85 0.40 5.38 0.55 0.003**
3.45 0.38 4.27 0.54 0.96 NS
S.D = Standard deviation. P = Probability level.
NS = Insignificant (p>0.05)
** = Significant at ≤ 0.01 ***= Significant at ≤ 0.001

Table 2 showed that in the control groups (B0) there was a highly
statistical significant difference (p≤0.001) between total etch and self etch
adhesive systems in silver uptake. Also, a statistical significant difference
(p≤ 0.01) was observed between total etch and self etch adhesive when
home bleaching were done before cavity preparation and restoration (B3).
No statistical significant difference was observed between total etch and
self etch adhesive systems whether in office bleaching were done before
10
Dentine
Nanohybride
composite
Silver deposits
Dentin
dentin
Nanohybridcomposite
Silver deposites
(B1) or after (B2) cavity preparation and composite resin restoration, also
same result were observed with (B4) home bleaching after cavity
preparation and composite resin restoration.












































Fig (1): SEM image of interface for
control group B0 bonded with total
etch adhesive.
Fig (2): SEM image of interface for
control group B0 bonded with self
etch adhesive.
dentin
Silverdeposits
Nanohybridecompositeresin
Fig (4): SEM image of interface for
home bleaching before cavity
preparation and composite restoration
specimen B3 bonded with self etch
adhesive.
Fig (3): SEM image of interface for
home bleaching before cavity
preparation and composite restoration
specimen B3 bonded with total etch
adhesive.
dentine
Silver
deposits
Nanohybride
composite
Dentin
Silverdeposits
Nanohybridecomposite
Dentin
11
Nanohybride
composite
Silver
deposites
dentin













































Silver
deposites
dentin
Nanohybride
composite
Nanohybride
composite
Silver
deposites
dentin
Silver
deposites
Nanohybride
composite
dentin
Fig (5): SEM image of interface for in-office
bleaching before cavity preparation and
composite restoration specimen B1 bonded
with total etch adhesive.
Fig (8): SEM image of interface for in-
office bleaching after cavity preparation
and composite restoration specimen B2
bonded with self etch adhesive.
Fig (7): SEM image of interface for in-
office bleaching after cavity preparation
and composite restoration specimen B2
bonded with total etch adhesive.
Fig (6): SEM image of interface for in-
office bleaching before cavity
preparation and composite restoration
specimen B1 bonded with self etch
dentin
Nanohybrid
composite
resin
Silver deposits
dentin
Nanohybrid
Composite
resin
Silver deposits
Fig (9): SEM image of interface for
home bleaching after cavity preparation
and composite restoration specimen B4
bonded with self etch adhesive.
Fig (10): SEM image of interface for
home bleaching after cavity preparation
and composite restoration specimen B4
bonded with totaletch adhesive.
12

Discussion
Dentists must be concerned about the effect of bleaching on the marginal
adaptation of bonded composite restorations . .
In the present study Class V cavity preparations were selected as it was
reported by Raskin et al in 2001 that 62.5% of the microleakage studies
used Class V preparations, which allow evaluation of both enamel and
dentin margins concurrently. The location and size of class V cavities
were based on the ISO/TS 11405 technical specification for adhesion
tests in dental structure and published literature (Raskin et al., 2001 and
Heintze S., 2007).
The application of bleaching procedures may occur prior to or after
restorative procedures that require bonding to enamel or dentin. In
subgroup B1 and B3 bleaching were done 7 days before cavity
preparation and composite resin restoration as suggested by Sundfeld et
al., in 2005 who proposed a gap period of at least 7 days between the use
of 35% hydrogen peroxide bleaching material and restorative procedures
that require acid etching and adhesive bonding materials. They mentioned
that the 7 days are a gap period in order to allow complete elimination of
residual peroxide which may interfere with resin polymerization.
Subgroups B2 and B4 received in-office or home bleaching after cavity
preparation and composite resin restoration by one month as
recommended by (Sung et al., 1999 and Nour Eldin et al., 2006).
To artificially age the specimens all specimens were received a
thermocycling regimen of 1,000 cycles between 5˚ c and 55˚ c, with a 30
seconds dwell time in water bath as suggested by Cencl et al., 2008. They
reported that composite resin restorations were affected by thermal
cycling only after 1.000 cycles/60 s dwell time at enamel margins or after
500 cycles/ 60 s dwell time at dentin margins. The thermocycling
13
procedure was used as enamel, dentin, and composite restorations have
different behavior when subjected to temperature variations due to their
different thermal expansion coefficient (International Organization for
Standardization-ISO/TS 11405). Consequently, adhesive failure becomes
obvious through dye infiltration at the tooth-restoration interface which
occurs after thermocycling. .
SEM is a well established technique to examine the interface between
dentin and restorative materials and represent important means of
assessing the defective adaptation of restorative materials (Carvalho et
al., 2004). Although the use of silver nitrate dye was effective in
detecting the nanoleakage (Sano et al., 1995), in this study ammoniacal
silver nitrate dye was used because of its efficiency in doing the job and
to eliminate the drawback of the regular silver nitrate which
demineralized the dentin due to its low PH (Pashley et al., 2002). The
silver ions at the tooth restoration interface of the specimens were
identified using EDX analysis supplied with the Scanning electron
Microscope
The results of this study showed that in the control group B0 both
total etch and self etch adhesive systems demonstrate the presence of
silver deposition at tooth restoration interface which was significantly
more distinct in case of self etch adhesive. This was in agreement with
Tay and Pashley., in 2003 Who reported that the self-priming and self-
etching adhesives are more hydrophilic and hence more permeable to
water derived from the underlying dentin, which is undesirable because
this permeability can lead to premature degradation of resin dentin bonds
over the time. Also, Silva Telles et al., in 2001 reported that the low PH
of self etch adhesives impair the polymerization of the resin monomers
and therefore does not allow the formation of a strong and stable hybrid
layer. The other explanation might be due to their different mechanisms
14
of bonding to tooth structure. ExciTE F is a total etch system which
completely removes the smear layer. AdheSE is a self etch adhesive
system modifies the smear layer instead of removing it completely. It was
demonstrated by Tay et al., 1999 that self etch adhesives might have
residual water within the adhesive dentin interface, which might affect
the polymerization of the resin composite. On the contrary Frankenberger
et al., in 2000, Oliveira et al., in 2002 and Gueders et al., in 2006 claimed
that self etch adhesives simultaneously etch and infiltrate the dentin and
overcome the problem of excess water or dehydration encountered in
using etch and rinse adhesives. They also assume that the lower primer
acidity in self etch adhesive promote less dentinal tubules opening which
allow easier sealing of the dentin surface. They proposed that the self
etching adhesives obtained higher dentin sealing capability than etch and
rinse adhesives.
Results also showed that with both bleaching system, total etch
bonded restorations showed less silver uptake than self etch bonded
restorations but not up to the statistical significance level except in pre-
restorative home bleaching, a statistical significance different was
observed. This could be attributed to the presence of alcohol in the Excite
F total etch adhesive system. It has been stated that alcohol-based
adhesive systems might minimize the inhibitory effect of oxygen because
of the interaction of alcohol and oxygen Titley et al., 1993; Attin et al.,
2004 ).
In the present study samples that bonded with total etch adhesive
system and treated by home bleaching showed statistical significant less
silver uptake than sample treated with in-office bleaching. One of the
factor that may contribute for this result is that carbamide peroxide
decompose after clinical application into urea, ammonia, carbon dioxide
and hydrogen peroxide which is the active ingredient and it constitute
15
nearly one third of active ingredient released from equal concentration of
hydrogen peroxide bleaching agent (Canay and Cehreli., in 2003).
It was found in our study that in-office bleaching whether done before or
after cavity preparation and restoration adversely affect the adaptation of
the total etch bonded restorations. This was in consistent with
Barkhordaret al., in 1997 who reported that hydrogen peroxide alters the
tubular permeability and interprismatic area, facilitating the persistence of
peroxide which inhibits polymerization and leading to high rate of
microleakage. Another consideration is the presence of dentinal tubule
that may enhance the rate of penetration of the bleaching agents and
residual oxygen diffusion which considered a strong oxidizing agents that
may cause denaturing of proteins in the organic components producing
changes that could reduce the performance of resin bond restorations and
impaired marginal adaptability. Moreover Cadenaro et al., 2006 found
that etching and rinsing procedures were not able to eliminate residual
oxygen from the bleached surface.
In our study the pre-restorative and post-restorative home
bleaching did not adverse the adaptation of the Nano-hybrid composite
restorations bonded by total etch or self etch adhesives used in the study.
This was in agreement with Crime 1992b, Klukowska et al.,2008; White
et al.,2008; yazici et al., 2010). Also it was noticed that the in-office and
home bleaching did not adverse the self etch bonded restorations. We
may attribute this finding to the type of adhesive used, as it was stated
that the effect of the bleaching agents on microleakage of composite resin
restorations differs according to the type of adhesive material used yazici
et al., 2010.
Results also showed that pre-restorative home bleaching showed less
silver uptake than the post-restorative home bleaching in all restoration
bonded with total each adhesive. Crim G., in 1992b and Owens et al., in
16
1998 did not find increased microleakage rates for the pre-restorative
bleaching samples and reported that pre-restorative bleaching by
carbamide peroxide did not affect the marginal seal of subsequently
placed restoration.
Conclusion:
Under the condition of this research it was concluded that
1- Total etch adhesive demonstrates superior marginal adaptation
compared to self etch adhesive.
2- Pre-restoration and Post-restoration Home bleaching doesn't adversely
affect the adaptation of nano-hybrid composite bonded with total etch
or self etch adhesive.
3- Marginal adaptation of nano-hybrid composite to home bleached
enamel is superior to that of in-office bleaching using total etch
adhesive.
4- Pre-restoration and Post-restoration in-office bleaching adversely
affect the adaptation of nano-hybrid composite bonded with total etch.
5- Pre-restoration and Post-restoration in-office bleaching doesn't
adversely affect adaptation of composite bonded with self etch
adhesive.
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